Travelling

Travel is exhausting.  Having RA certainly doesn’t make things any easier.  What’s the best way to transport meds?  What if prescriptions need to be refilled during the trip?  Is it possible to spend twelve-hour days in the car without every joint gelling?  To have the best trip possible, it’s good to plan ahead.

My oldest child is now a college freshman, and to make the transition easier on everyone, our whole family made the trip to help big brother settle into his dorm.  Our first day we travelled south to Portland, OR, and across to Boise, ID.  The second day we drove to Denver.  Our third day wasn’t quite as long because we didn’t leave Denver until after lunch, but we still travelled through Oklahoma to northern Texas.  The fourth day we completed the first leg of our journey and delivered our son to his school, two-thirds of the way across the country.  We spent a few days there, and are now half-way home.  Aside from everyone being tired of long car trips day after day, it has gone well.

Refills

Your pharmacist will not love you if you stop by the pharmacy on your way out-of-town and ask for early refills on everything.  I talked with my pharmacist a month in advance to find out what special requirements they had for getting meds early.  My pharmacy wanted a week’s notice.  That week gave the pharmacy time to contact my insurance company to get a vacation override.  I picked up all my refills two days before we left town (allowing a small cushion in case something went wrong).  Your pharmacy might be different, so talk to the pharmacy staff and make sure you get all your refills before it’s time to leave.

Transporting Meds

When travelling out-of-country, it’s a good idea to keep all prescriptions in their original bottles with the original labels.  Since I was not leaving the country, I filled all my pill boxes and left the bottles at home.  The biologic required special handling, though.

Biologics need to be refrigerated, but it’s not necessary to buy one of those refrigerators that plug into the car’s lighter-socket.   $2,700 worth of medicine is worth some TLC.  I placed my pre-filled syringes into the little insulated travel-bag from Humira, along with the bag’s ice pack.  I then placed that entire bag into the insulated travel-bag from Enbrel, along with its ice pack.  That bag then went into our large ice chest.  I don’t think the medicine would have stayed cold enough in only one bag.  Everywhere we’ve travelled, the weather was in the 90′s, and most nights all of the ice packs were melted.  Fortunately, the medicine was still cold.

On my first trip travelling with Enbrel, one of the hotel refrigerators got too cold and froze my medicine, so this time I took extra precautions.  Every night, I left the medicine in the smallest insulated bag (unzipped about one inch) and placed it into a refrigerator.  The insulation protected the medicine from freezing.  If you don’t have access to multiple insulated bags, my pharmacist suggested wrapping the medicine in a towel before placing it into the hotel refrigerator.

No Gelling

Gelling is the phenomenon that describes stiff joints after inactivity due to synovial fluid that doesn’t stay where it belongs.  The key to preventing gelling (if your meds aren’t doing that for you), is to keep moving.  Move the hands, move the ankles and knees.  Move the shoulders and hips and any other joints that are likely to otherwise stiffen.

Flexing the hands periodically can help if you’re driving.  I like to knit while travelling (in the passenger seat).  This keeps my hands, wrists, and elbows moving, and gives me something to show for all that time sitting in the car.

Ankles should be moved, too.  If you write the alphabet with each foot, that will nicely flex your ankles and prevent stiffness (and strengthen the ankles if you put weights on your feet).  I find that simply by changing position so that I can move my feet around, I also move my knees.

A good shoulder roll and upper-arm stretch takes very little time, and is quite helpful in preventing stiffness.

The final thing that I do to keep from getting too stiff is to stop and walk around at least every two hours.  The best way to get the driver to make frequent stops at rest areas is to make sure everyone drinks plenty of fluids – easy enough when the weather is hot, but a bit trickier during the winter.

Many hotels now have a fitness center, so I’ve found it very easy to exercise at the end of a long day, which is another way to make travelling with RA a little easier.

Do you have special things you do to make travel easier?

Nummular Dermatitis & TNF-Inhibitors

Nummular dermatitis (aka discoid eczema) has an incidence of 2 in 1000 people, mostly men in the age range of 55-65.  However, treatment with a TNF-inhibitor is also a risk factor.

Like many medical terms, the name nummular dermatitis  comes from Latin roots:

  • nummular – from nummus - coin
  • dermis – a layer of skin
  • itis – inflammation

So, nummular dermatitis is coin-shaped inflamed patches of skin.  This rash can itch and burn, even to the extent that it disrupts sleep.  Some people, however, are fortunate enough to skip the unpleasant sensations that typically accompany this unsightly rash (sometimes there are advantages to peripheral neuropathy).

This rash is not contagious.

Appearance

Nummular dermatitis begins as a group of blisters or tiny red dots.  It quickly becomes a round or oval-shaped patch of red (sometimes pink or brown) skin.  Multiple patches are possible; they can be as small as two millimeters, or as large as four inches.  The rash usually appears on the extremities (arms, legs, feet, hands) or torso.  Thankfully, it is rare for patches to appear on the face.

  

Diagnosis

This rash is unique in appearance and can often be diagnosed based on a visual examination.  Usually no expensive tests are needed, but occasionally the rash will look like ringworm, in which case a doctor might need to take a sample to make an accurate diagnosis.

Causes

There are no known causes of nummular dermatitis, however a Dutch study of RA patients done in 2005 showed that 25% of RA patients on TNF-inhibitors needed referral to a dermatologist, vs. 13% of RA patients who had never taken a TNF-inhibitor.  Fortunately, only a small number had nummular dermatitis.  Of note, hepatitic C patients treated with a TNF-inhibitor have an increased risk of nummular dermatitis.  It will be interesting to see the results of follow-up studies now that TNF-inhibitor use is more common in the treatment of RA.

Treatment

Home treatments aren’t enough to deal with nummular dermatitis. Without adequate treatment, this rash can stick around indefinitely. Even with medical treatment, the rash can take months to resolve – some sources say it sometimes takes a full year for the rash to go away.

The goal of treatment is to:

  • reduce inflammation
  • repair the skin
  • rehydrate the skin
  • if infected, treat the infection

Credit:  http://s252.photobucket.com/albums/hh18/Jane-emma18/?action=view&current=Gumby.jpg&newest=1To reduce inflammation, prescription-strength steroid cream or ointment can be rubbed into the rash two-three times daily.  Unless you are Gumby, if your rash is on your back, you will need assistance with the application.  Oral steroids can be used when topical steroids are ineffective (this also eliminates the need for an assistant).

To increase absorption, the steroid cream/ointment should be applied to wet skin – particularly after a shower or twenty-minute soak.  Following application of the topical medicine, a good moisturizer should be applied to wet skin.  Some people recommend covering the medicated areas (ie with plastic wrap) for an hour to hold in the moisture.  Gently pat yourself dry; do not rub with a towel and remove the steroid cream & moisturizer.

Another treatment option – when topical steroids fail – is light therapy (UVB).

Although home treatments alone can’t cure nummular dermatitis, there are a few things you can do.  Take good care of your skin and be sure to moisturize it well.  Also, avoid potential flare-triggers.

A few of the things that sometimes cause flare-ups of this condition are:

  • frequent use of detergents or harsh soaps
  • hot tub usage
  • extreme temperatures (very hot or very cold)
  • extremes in humidity (or lack thereof)
  • rough wool clothing
  • skin injury (ie cut, burn, or insect bite)
  • some medications  (examples include accutane, neomycin, and TNF-inhibitors)
  • sensitivity or allergy to rubber, nickel, cobalt, formaldehyde, or mercury

This means that if your routine is to take a long, hot shower first thing in the morning before dressing in a nice warm, wool sweater and cozy wool socks, you might need to modify your routine.  Make it a shorter lukewarm shower, apply a good moisturizer to your skin, then dress is loose cotton clothing.  If your workout routine later includes spending twenty minutes in a steam room, followed by half an hour soaking/stretching in a hot tub, followed by an hour in a swimming pool, ten minutes in the dry sauna, and then another hot shower, you’re intentionally doing five of the eight things you need to avoid.

See a doctor for accurate diagnosis and treatment if you suspect nummular dermatitis.

Vocabulary for Reading Medical Literature about Nummular Dermatitis

erythematous – red
papules – bumps
vesicles – very small blisters
pruritic – itchy
xerosis – abnormal dryness

References

Arthritis Research & Therapy
Medscape
Skinsight
American Academy of Dermatology
DermNet NZ
British Association of Dermatologists